Caldwell-Luc Procedure: Operative Technique

Anesthesia

Caldwell-Luc may be performed under local or general anesthesia depending on the patient's preference, the surgeon's experience, the health and age of the patient, and the complexity of the proposed procedure. Local anesthetic with epinephrine should be injected into the soft tissue over the maxillary sinus and the common wall of this sinus and the nose. Several minutes should be allowed to lapse before beginning surgery to permit good anesthesia and vasoconstriction of blood vessels.

Operative Technique

Surgery begins with retraction of the upper lip to expose the anterior wall or face of the maxillary sinus. A horizontal incision is made above the gums to expose the bony front wall of the maxillary sinus.

Coronal cadaver section showing maxillary sinus (MS). The anterior wall of the sinus is fenestrated as the first step of the Caldwell Luc. An antrostomy is performed at either the middle meatus (*) beneath the middle turbinate (MT) or inferior meatus (IT). In fenestrating the face of the maxillary sinus, it is important to not injure the infraorbital nerve (ION).

Caldwell Luc begins with retraction of the upper lip and incising the mucous membrane above the teeth. There are several variations of the placement of this incision relative to the teeth (with permission from Donald, P., et al. The Sinuses. Raven Press; New York, 1995).

A surgical retractor and the index finger of the assistant are shown providing exposure to the face of the maxillary sinus. A similar incision to that used in the preceding artist drawing was used on this patient.

The soft tissue over the maxillary sinus is elevated to visualize the anterior wall of the sinus. Various instruments may then be employed to fenestrate or make an opening into the maxillary sinus. In making such a fenestration, the surgeon must be careful to avoid the roots of the maxillary teeth (upper jaw), and to limit the opening to that which is necessary to perform the planned surgery.

The former is important because the teeth may be devitalized if their blood supply or nerves are injured by the fenestration. The latter is important because the larger the fenestration the more likely the soft tissue of the face is going to post-operatively collapse into the maxillary sinus.

This may have no consequence, or may prevent the sinus from freely draining into the nose or cause a cosmetic deformity. A third potential complication is injury to the infraorbital nerve. This nerves is within the roof of the maxillary sinus to give sensation to mid face region and teeth. During fenestration the nerve may be directly injured or stretched leaving the patient with temporary or permanent numbness.

Following an incision into the soft tissue over the maxillary sinus, the bony face of this sinus is exposed.

Illustration of fenestration of the bony face of the maxillary sinus (with permission from Donald, P., et al. The Sinuses. Raven Press; New York, 1995). In figure A, a surgical chisel is illustrated creating an opening into the maxillary sinus. Figure B shows a "generous" fenestration.

Following fenestration of the maxilla, the dentigerous cyst and tooth (arrow) are visualized within the floor of the sinus (dotted line).

After completing tumor removal or other procedures which require a Caldwell-Luc, an opening into the nose is routinely performed. This antrostomy is intended to either temporarily drain the maxillary sinus of post-operative blood or to provide a long term communication into the nose.

Traditionally this opening into the nose is placed below the inferior turbinate or the area known as the inferior meatus. However, the maxillary sinus normally drains to the middle meatus or below the middle turbinate. Increasingly, a middle meatus antrostomy is being utilized as a more physiologic antrostomy. Following all of the surgical procedures, the soft tissue over the maxillary sinus is re-approximated with sutures.